Provider Manual. ChoiceBenefits. BayCare Health System Medical Plan

Transcription

1 2019 Provider Manual ChoiceBenefits BayCare Health System Medical Plan 1

2 Table of Contents BayCare... 2 BayCare Exclusive Network... 2 Rules unique to Cigna BayCare Members... 2 Provider Relations Representative... 2 Benefit Services... 2 Cigna... 2 Medical Options... 3 Choice Share... 3 Choice HSA... 3 Choice Premium... 4 Out of Area Plans... 4 Dependents Who Are Out-of-Area... 4 Plan Summaries... 4 Member Eligibility... 5 Determining Eligibility... 5 Eligibility Verification... 5 Identification Cards... 5 Quick Reference of Plan Rules/Contact Information... 7 Precertification... 8 Precertification is required for:... 8 Precertification Process... 8 Emergency Situations... 8 Precertification Information... 8 Infusions... 9 Pharmacy Formulary Prior Authorization Quantity Limits Step Therapy Specialty Pharmacy Manager Claims Electronic Claim Submission Paper Claim Submission Claim Status Cigna Contact Information

3 BayCare The BayCare Medical Plan is a self-insured plan designed by BayCare, administered by Cigna and is provided to the employees of BayCare Health System, Inc. and their dependents. BayCare includes: Mease Countryside, Mease Dunedin, Morton Plant, Morton Plant North Bay, St. Anthony s, St. Joseph s, St. Joseph s Women s, St. Joseph s Children s, St. Joseph s-north, St. Joseph s-south, South Florida Baptist, Winter Haven, and Bartow Regional Hospitals BayCare Exclusive Network The BayCare Exclusive Network is custom designed to use BayCare Health System facilities and providers who have privileges at BayCare facilities. Our medical plan requires the use of BayCare facilities whenever possible because as a health care organization, BayCare is able to provide services to its members at a greatly reduced cost allowing savings for both the medical plan and the members. The network of both physicians and facilities may be accessed at Rules unique to Cigna BayCare Members Labs must be drawn at or sent to a BayCare lab (if collected in your office), unless your contract with Cigna or BayCare does not include the CPT code as covered. Refer only within the BayCare Exclusive Network. All DME must be provided by BayCare HomeCare and is covered at 100% for Choice Share and the Premium plan and 100% after deductible for Choice HSA. DME billed for up to $700 may be provided in your office without authorization if it is billed under your tax ID. DME supplied in office should be for emergency or urgent situations only. If the DME can be ordered or rented, it should be referred to BayCare HomeCare. All DME provided in office will be subject to deductible and coinsurance for the Share and HSA plan and subject to a $50 copay for the Premium plan. All radiology, including high tech radiology, must be referred to a BayCare facility unless done in your office, under your tax identification. No precertification is needed. Home Care must be provided by BayCare HomeCare. Mental Health services must be provided by BayCare Behavioral Health. Pharmacy Benefit Manager is CVS Caremark. Provider Relations Representative Kimberly Muntges, Health Plan Coordinator (727) or Kimberly.muntges@baycare.org provides education to BayCare Exclusive Network Providers to assist staff in understanding BayCare s Medical Plan and our relationship with Cigna. Kim also is your contact person for any changes in your practice- addition or termination of physicians in your practice or changes in demographic information including tax id number updates. Benefit Services Benefit Services is a BayCare department responsible for answering member s questions about their benefits. You can direct members to Benefit Services for questions on their benefits. The phone number is (727) or toll free (877) Cigna CIGNA provides eligibility information and customer service, as well as processing and paying medical claims. They will also coordinate utilization review, precertification and services needed when a specialty gap exists within the BayCare Exclusive Network. CIGNA has a unique customer service phone number for BayCare provider and member inquiries:

4 Medical Options A BayCare member has several plan options to choose from for medical coverage. The following is a brief highlight of each plan option. Please refer to the Schedule of Medical Benefits on page 4 for a more detailed outline of each plan. The following are common rules shared by all Plan Options: BayCare follows the same precertification guidelines as Cigna, including for lab tests. Requests for precertification should be completed by the physician rendering or ordering the service and sent to CIGNA. Services requiring precertification that have not been authorized by CIGNA will not be covered. If the Member or the Member s provider believes that they are in need of a service or physician not available within the BayCare Exclusive Network, their physician must contact CIGNA. If CIGNA verifies that the service is not available within the BayCare Exclusive Network, CIGNA will coordinate the care and refer the Member to a CIGNA contracted provider Services provided outside the BayCare Exclusive Network that have not been authorized by CIGNA will be denied. There are no retroactive authorizations. The BayCare Exclusive Network Directory is located at To verify deductibles and coinsurance, call CIGNA at Preventive services as defined by the ACA and outpatient labs covered by the plan are covered at 100%. Choice Share Member has open access to any provider in the BayCare Exclusive Network. Office visits are subject to a $15 co-pay for PCP office visits and $30 copay for specialist visits. Preventive visits are paid at 100%. All other services are subject to an annual deductible. This is a shared deductible and may be met by an one member or any combination of members on the policy The deductible is $500 for employee only The deductible is $1,200 for an employee covering a spouse and/or child(ren). After the deductible is met, the plan pays 80% of the allowable charge, the member pays 20% until the out of pocket is met. Then the plan pays at 100%. The OOP max is $2,700 for employee only. The OOP max is $6,500 for an employee covering a spouse and/or child(ren). Choice HSA Member has open access to any provider in the BayCare Exclusive Network. All services, including office visits, are subject to an annual deductible. The deductible is $1,500 for employee only. The deductible is $3,000 for an employee covering a spouse and/or child(ren). BayCare will contribute to the employee s HSA account if member opens their HSA timely. The member may use the funds in his/her HSA account to pay out-of-pocket costs. For coverage that begins mid-year, BayCare contributes a pro-rated amount to their HSA if they open their HSA timely. After the deductible is met, the plan pays 80% of the allowable charge, the member pays 20% for most services until the out of pocket maximum is met. The OOP max is $3,500 for employee only. The OOP max is $7,000 for an employee covering a spouse and/or child(ren). 3

5 Choice Premium BayCare is offering team members a new medical plan option, the Premium plan. This plan is copay based for all services with no deductible. Member has open access to any provider in the BayCare Exclusive Network. The OOP max is $1,500 for employee only. The OOP max is $3,000 for an employee covering a spouse and/or child(ren). Out of Area Plans The Choice Share Out-of-Area, Choice HSA Out-of-Area and Premium Out-of-Area plans offer the same benefit levels but are available only to members and their dependents who live outside Hillsborough, Pasco, Pinellas, or Polk counties. The member must enroll in this additional access, it is not automatic. The members have open access to the Cigna Open Access Plus network as well as the BayCare Exclusive Network. Services outside these networks are covered with precertification only. If precertification is not obtained, no benefits are paid. Dependents Who Are Out-of-Area Dependents enrolled in Out-of-Area coverage will have the same coverage as the Member, but will be able to use the Open Access Plus network in addition to the BayCare Exclusive Network. Their services are applied to the family deductible and out of pocket maximums. Plan Summaries Choice Share Choice HSA Premium Deductible TM Only / TM + Dependent(s) Out of Pocket Maximum TM Only / TM + Dependent(s) HSA Contribution TM Only / TM + Dependent(s) $500 / $1,200 $1,500 / $3,000 $0 / $0 $2,700 / $6,500 $3,500 / $7,000 $1,500 / $3,000 Not applicable $600 / $1,200 Not applicable Preventive Services 100% covered 100% covered 100% covered BayCare Anywhere $10 co-pay 80% after deductible $10 co-pay Primary Care Physician Co-pay $15 co-pay 80% after deductible $10 co-pay Specialist Co-pay $30 co-pay 80% after deductible $20 co-pay BayCare Urgent Care $30 co-pay 80% after deductible $20 co-pay Inpatient admission 80% after deductible 80% after deductible $100 co-pay Outpatient services 80% after deductible 80% after deductible $20 copay Physical, Speech, Occupational Therapy-40 visits per year per type 80% after deductible 80% after deductible $20 copay Emergency Room 80% after deductible 80% after deductible $75 co-pay Prescription Drug Coverage 30-day supply 90-day supply 30- or 90-day supply 30-day supply 90-day supply Generic $10 $25 80% after deductible $10 $25 Preferred Brand 20% up to $100 max 20% up to $200 max 80% after deductible $30 $75 Non-Preferred Brand 30% up to $150 max 30% up to $250 max 70% after deductible $50 $125 Specialty 30% up to $150 max Not available 70% after deductible (90-day supply not available) $50 Not available 4

6 Member Eligibility Determining Eligibility It is important to determine member eligibility prior to rendering service. CIGNA recommends verification of eligibility prior to the patient s appointment date. Members are responsible for presenting their BayCare CIGNA member identification card. Eligibility Verification In addition to viewing the member s ID card, the provider s office may verify a member s eligibility by accessing Cigna s Secured Provider Portal, the automated Interactive Voice Response (IVR) system or by contacting Customer Service. The provider Web site allows access to eligibility information 24 hours a day and 7 days a week. Visit Identification Cards The following information can be found on a BayCare Cigna member ID card: Member name Plan type Employer group name Employer group plan # Member ID Member co-payment amount (if applicable) Claims mailing address CIGNA and BayCare Logo MultiPlan logo (back of card) Customer Service and Precertification phone number Choice Share Choice HSA 5

7 Premium Choice Share Out-of-Area Choice HSA Out-of-Area Premium Out-of-Area 6

8 Quick Reference of Plan Rules/Contact Information Service Labs Must be performed by BayCare Labs Benefit / Service Provider Can be drawn at: BayCare facilities Physician s office If your contract with Cigna or BayCare does not include the lab CPT code as covered, you may draw the lab in your office but it must be sent to BayCare labs to be performed, even in proprietary lab arrangements. Referrals BayCare Exclusive Network- no referrals needed No out of network benefit without prior authorization Durable Medical Equipment (DME) Should be filled through BayCare HomeCare: Up to $700 billed may be provided in your office without authorization if billed under physician s TIN and an emergency/urgent situation. Deductible and coinsurance apply for Share and HSA; $50 copay for Premium. Home Care BayCare HomeCare: Mental Health/Substance Abuse BayCare Behavioral Health: Radiology Including High Tech Radiology CIGNA Pharmacy Benefit Manager CVS Caremark: Diabetes Supplies No authorization required when provided within the BayCare Exclusive Network Plan members who meet the specific requirements will receive diabetes supplies (i.e., insulin pens/syringes, meters, test strips and lancets) for one year at no cost. For more information, please contact DiabetesSupplyProgram@baycare.org 7

9 Precertification Precertification is a review of a proposed treatment, service or procedure prior to that treatment, service or procedure. Providers are required to obtain Precertification for all inpatient services, all outpatient surgeries and some select outpatient procedures. By obtaining a precertification, a provider can verify if services are covered, medically necessary, provided at the appropriate level of care and will be eligible for coverage payments. Precertification is required for: Hospital admissions All outpatient surgeries performed in a hospital or in a surgical center Selected Outpatient Procedures All Unlisted Codes Any service that is potentially cosmetic or potentially investigational/experimental High Risk Maternal Procedures Infertility/Family Planning/Surgical Contraception Select High Volume or High Risk Procedures Transplant Evaluations Home Health Care, including IV therapy Skilled Nursing Facilities Durable Medical Equipment (DME) billed over $700 Air Ambulance, when used for non-emergency Medical Conditions Genetic Testing Renal Dialysis All out of network services Radiology including high tech radiology (MRI, CT and PET scans) does not require prior authorization. All high tech radiology must be performed at a BayCare facility. BayCare does not use MedSolutions, Inc. For eligibility, please call Cigna at Precertification Process The admitting physician is responsible for obtaining precertification. The process may be initiated by contacting the number on the member s ID card or through the Cigna Provider Portal at A nurse reviewer processes the precertification request. The information is screened to verify that it meets Cigna s utilization review criteria and if so, the nurse reviewer will authorize the precertification request. This process is normally brief. In some cases, Cigna may need additional information from the patient and/or physician. If the nurse is unable to complete the precertification, it is referred to a physician for review. A Cigna Medical Director or specialist consultant reviews the case and makes a determination. Authorization review turnaround times for medical services and supplies are completed according to federal laws and regulations and URAC standards. Cigna physician reviewers may call the treating physician to obtain additional information or clarify the treatment plan. Upon completion of the precertification process, a confirmation letter is mailed to both the member and treating provider. Emergency Situations If services that require precertification are rendered on an emergency basis, precertification must be obtained within 72 hours of the onset of treatment. Precertification Information The following information is needed to process a precertification request: Employee s name and ID number Plan number and employer s name Patient s name and date of birth Admitting/attending physician s name and telephone number Name of facility Date of proposed treatment Diagnosis, treatment plan, significant clinical details, discharge plan Requested length of stay or number of treatments Name of provider who referred care If available, a CPT 4 code(s) for surgical procedure(s) or ICD-10 Code(s) for diagnosis 8

10 Infusions Precertification by Cigna is required for all infusions. The referring physician is responsible for obtaining precertification. The process may be initiated by contacting Cigna using the number on the member s ID card and providing the precertification information. The request is then reviewed by Cigna for medical appropriateness and coverage. If you infuse the medication at your office, contact BayCare Home Care at to secure the medication. The BayCare Medical Plan does not reimburse for medications purchased by the physician s office (buy-and-bill). If your patient wants to receive the medication at a hospital/infusion center, they may do so only at a BayCare facility. Please provide the precertification number to their selected facility so that the member may schedule an appointment. If your patient would like to receive the medication infused at home, please fax a referral to BayCare Home Care at BayCare Home Care will contact the member directly to schedule the appointment. 9

11 Pharmacy Formulary Our pharmaceutical benefits manager is CVS Caremark. For complete information of medications on the formulary, log into or call a CVS Caremark Customer representative. BayCare Team Members may only fill scripts at a CVS Pharmacy, Publix Pharmacy or BayCare HomeCare (as appropriate). Generics should be considered the first line of prescribing. If a generic is available and the member chooses to use a brand drug the member pays the generic copayment plus the difference in the cost between the generic and the brand drug. This is true even if DAW (dispense as written) is included on the prescription. Choice Share/Choice Share Out-of-Area: The member s co-payments are: Generic $10.00 Preferred Non-Preferred Specialty 20%, $100 max. 30%, $150 max. 30%, $ max. If a generic is available and the member chooses to use a brand drug the member pays $10.00 plus the difference of the cost between the generic and brand drug. Choice HSA/Choice HSA Out-of-Area: Most prescriptions are subject to the deductible and coinsurance. However, some preventive generics are covered at 100 percent. These medications are generally recognized as intended to lower risk factors and prevent disease, including some cholesterol-lowering agents, blood pressurelowering medications, anti-asthmatics and Type II diabetes hypoglycemic. All Generic and Preferred Brand medications are subject to the deductible and 20 percent coinsurance. All Non- Preferred Brand and Specialty medications are subject to the deductible and 30 percent coinsurance. Premium/Premium Out-of-Area: The member s co-payments are: Generic $10.00 Preferred $30.00 Non-Preferred $50.00 Specialty $50.00 Prior Authorization Some drugs require prior authorization. In these instances, the physicians must submit medical criteria for review and approval before the prescription can be filled. To obtain prior authorization, call CVS Caremark at Quantity Limits To promote appropriate medication use and enhance patient safety, quantity (dispensing) limits have been placed on some drugs. These limits are based on accepted pharmaceutical guidelines and FDA-approved manufacturer labeling. Step Therapy Step therapy helps encourage the appropriate, cost-effective use of certain medication in accordance with current medical literature, manufacturer recommendations, Food and Drug Administration guidelines and available cost information. Step therapy requires the use of one or more pre-requisite therapy medications before a step-therapy medication will be covered. However, if it is medically necessary to be initially treated with a step-therapy medication, the physician can contact CVS Caremark to request coverage as medical exception. Specialty Pharmacy Manager BayCare utilizes BayCare HomeCare to manage high-cost specialty drugs. This specialty drug program is designed to help our members manage their diseases and conditions by providing support and compliance programs not always available through the local pharmacy. When prescribing any high cost drugs, fax the prescription to: BayCare HomeCare ( ). For questions call ( ). 10

12 Claims Electronic Claim Submission Cigna contracted providers are strongly encouraged to bill electronically for covered services. HIPAA 5010 compliant claims should be sent to electronic payer ID Cigna electronic payer ID is Cigna offers the 835 transaction (electronic remittance advice) through ProxyMed and WebMD. Paper Claim Submission Providers may submit paper claims using a HCFA/CMS 1500 form or UB92 form, as applicable. Paper claims should be submitted to the address on the member s ID card. If a member ID card is not available, paper claims may be submitted to the National Mail Center at the following address: Cigna P.O. Box Chattanooga, TN Claim Status The Cigna Secured Provider Portal allows providers to access claim status information 24 hours a day, 7 days a week, at By calling the number on a member s ID card, providers can access either the automated IVR system for claim status or speak to a Customer Service Representative. EDI claim inquiry response transactions (276/277) can be conducted through ProxyMed. Cigna Contact Information Web Site: Claims, Benefit and Eligibility: For eligibility, pretreatment authorization, benefits and claim inquiries, call the number on the member s identification card or visit the provider Web site. Member Customer Service: For BayCare Health System Members: (877) Claims Submission: Cigna P.O. Box Chattanooga, TN EDI Payer ID: Cigna Appeals: Medical Necessity A Customer Service Representative will direct caller to the nurse who is responsible for a particular member s case. Direct contact information is provided on each denial letter. (800) Appeals Mailing Address: Cigna Dispute & Appeal Resolution Process P.O. Box 668 Kennett, MO Complaints/ Concerns: (800)